<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML>
	<HEAD>
		<TITLE>Employee Insurance Signup</TITLE>
	</HEAD>
	<BODY BGCOLOR="#FDF5E6">
		<CENTER>
			<H1>
				Employee Insurance Signup
			</H1>
			<FORM ACTION="/testjsp/SubmitInsuranceInfo">
				Name:
				<INPUT TYPE="TEXT" NAME="name">
				<BR>
				Employee ID:
				<INPUT TYPE="TEXT" NAME="employeeID">
				<BR>
				Number of Children:
				<INPUT TYPE="TEXT" NAME="numChildren">
				<BR>
				<INPUT TYPE="CHECKBOX" NAME="married" VALUE="true">
				Married?
				<BR>
				<CENTER>
					<INPUT TYPE="SUBMIT">
				</CENTER>
			</FORM>
		</CENTER>
	</BODY>
</HTML>